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CORE TOPICS IN PERIOPERATIVE MEDICINE
CORE TOPICS IN PERIOPERATIVE
MEDICINE
by
Jonathan Hudsmith BM FRCA
Department of Anaesthesia
Peterborough Hospitals NHS Trust
Dan Wheeler MA BM BCh MRCP FRCA
Clinical Lecturer in Anaesthesia
University of Cambridge
Arun Gupta MA MBBS FRCA
Director of Postgraduate Medical Education
University of Cambridge
London ♦ San Francisco
cambridge university press
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo
Cambridge University Press
The Edinburgh Building, Cambridge cb2 2ru, UK
First published in print format
isbn-13 978-1-841-10139-2
isbn-13 978-0-511-16584-9
© Greenwich Medical Media Limited 2004
2004
Information on this title: www.cambrid
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/9781841101392
This publication is in copyright. Subject to statutory exception and to the provision of
relevant collective licensing agreements, no reproduction of any part may take place
without the written permission of Cambridge University Press.
isbn-10 0-511-16584-6
isbn-10 1-841-10139-7
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guarantee that any content on such websites is, or will remain, accurate or appropriate.
Published in the United States of America by Cambridge University Press, New York
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Contents
Preface vii
Contributors ix
1.Perioperative management of cardiovascular disease 1
John McNamara
2.Perioperative management of respiratory disease 13
Tim Clarke
3.Perioperative care of children 19
Warren Fisher
4.Perioperative management of the obese patient 25
Anand Sardesai
5.Perioperative management of the elderly patient 33
Karen Pedersen
6.Perioperative management of emergency surgery 43
Jeremy Lermitte and Jonathan Hudsmith
7.Perioperative fluid management 55
Iain MacKenzie
8.Perioperative management of coagulation 65
Andy Johnston
9.Perioperative management of steroid therapy 73
Fraz Mir and Michael Lindop
10.Perioperative management of endocrine disease 79
Dan Wheeler and Ingrid Wilkins
11.Perioperative management of diabetes 91
Mike Masding and Wendy Gatling
12.Causes and treatment of aspiration 99
Paul Hughes
13.Transfusion and blood products 105
Andy Johnston
14.The critically ill patient 111
Vilas Navapurkar
15.Inotropes 121
Andy Gregg
16.Arterial blood gases 127
Simon Fletcher
17.Drugs used in anaesthesia and sedation 137
Mike Palmer
18.Local anaesthetics 145
Sue Abdy
19.Monitoring used in the perioperative period 153
Ian Bridgland and Katrina Williams
20.Deep vein thrombosis and thrombo-embolic disease prophylaxis 165
Jonathan Hudsmith
21.Postoperative nausea and vomiting 173
Pete Young
22.The management of perioperative pain 179
Parameswaran Pillai and Richard Neal
23.High dependency and recovery units 191
Helen Smith
24.Postoperative hypoxia 199
Mark Abrahams
25.Postoperative hypotension 207
Chris Sharpe
26.Postoperative complications 213
Dan Wheeler and Jeremy Lermitte
27.Perioperative scenarios 237
Dan Wheeler and Parameswaran Pillai
28.Multiple choice questions 257
Quentin Milner
Index 277
Contents
vi
Preface
Undergraduate medical education is continuously changing to meet
the requirements for the training of future medical practitioners. Over
the last few years the concept of perioperative medicine has evolved
encompassing the preoperative assessment and optimisation of patients,
the intraoperative and postoperative management of these patients and
importantly the recognition, diagnosis and treatment of the critically ill
patient. The relevance of this to undergraduate medical students is
undeniable and a number of medical schools have now incorporated
a module of Perioperative Medicine into their curricula for medical
students.
The aims of this book are to provide concise, informative chapters on
many aspects of perioperative medicine, allowing medical students to
bridge the gap between their clinical attachment in this specialty, first year
house officer jobs and preparation for postgraduate examinations. We
make no apology for repeating important messages and subsequently
there may be some crossover of subject matter between chapters.
Changes to the structure of Senior House Officer training will result in
incorporation of a Foundation year for the majority of newly qualified
doctors. This book covers many of the situations and problems that these
doctors will have to face. By providing a broad overview of the
perioperative period, this text can be a very useful quick reference guide.
Effectively caring for patients in the perioperative period is a complex
and demanding job. Doctors and nurses need to be able to detect early
signs of any problems during this time, so that interventions can be
planned to optimise outcome for their patients. This book should help
staff achieve this goal.
This book will also be useful to those preparing for Surgical, Anaesthetic
and Accident and Emergency postgraduate examinations. Nurses and
other healthcare professionals, who are taking on increasing clinical
responsibilities within the perioperative period, will also find this book
invaluable.
Jonathan Hudsmith
Dan Wheeler
Arun Gupta
August 2003
Contributors
Sue Abdy MBBS DRCOG FRCA
Department of Anaesthesia
Queen Elizabeth Hospital, King’s Lynn
Mark Abrahams MBChB DA FRCA
Department of Anaesthesia
Norfolk & Norwich University Hospital NHS Trust
Ian Bridgland MBBS MSc DRCOG FRCA FANZCA
Department of Anaesthesia
St. Vincent’s Hospital, Sydney, Australia
Tim Clarke MBChB FRCA
Department of Anaesthesia
Blackburn Royal Infirmary
Warren Fisher MBChB FRCA
Department of Anaesthesia
Royal Berkshire Hospital, Reading
Simon Fletcher MBBS FRCA
Department of Anaesthesia
Norfolk & Norwich University Hospital NHS Trust
Wendy Gatling MBChB DM FRCP
Department of Medicine & Diabetes Centre
Poole Hospital NHS Trust
Andy Gregg BM MRCP FRCA
Neurocritical Care Unit
Addenbrooke’s NHS Trust, Cambridge
Arun Gupta MA MBBS FRCA
Director of Postgraduate Medical Education
University of Cambridge
[...]... history, examination and investigations 2 Cardiac risk and surgery 4 Cardiac risk and anaesthesia 4 Ischaemic heart disease and angina 6 Hypertension 7 Cardiac failure 7 Cardiac dysrhythmias 7 Valvular heart disease 8 Pacemakers 8 1 Core topics in perioperative medicine Introduction 1 Cardiovascular disease is common in the surgical population, occurring in at least 10% of patients presenting for surgery... Guideline Update Perioperative Cardiovascular Evaluation for Non-cardiac Surgery A Report of American College of Cardiology/American Heart Association Task Force on Practice Guidelines, November 2002 11 2 Perioperative management of respiratory disease Tim Clarke Common diseases 14 History 14 Examination and investigations 15 13 Core topics in perioperative medicine 2 Respiratory disease is common in. .. The history and examination should guide investigations in children and while there may be little place for the routine blood tests that are taken in Perioperative care of children adults, appropriate investigations are mandatory where there is a good indication In some cases, where blood sampling is known to be difficult, it is worthwhile discussing the investigations with senior clinicians It may be... period Administer supplemental oxygen, which should be humidified if possible to prevent secretions from desiccating When administering oxygen 17 Core topics in perioperative medicine 2 to patients with type II respiratory failure it is wise to use a fixed performance facemask, i.e one that delivers a fixed concentration of oxygen irrespective of the patient’s breathing pattern Major abdominal or thoracic... – raised bicarbonate may indicate chronic CO2 retention When recording arterial blood gases, always remember to note down the concentration of oxygen that the patient was breathing at the time (air ϭ 21% oxygen) Respiratory failure is defined as an arterial Pao2 of 8.0 kPa or less when breathing air It is divided into type I and type II 15 Core topics in perioperative medicine Type I respiratory failure... months → 30% 3–6 months → 15% Ͼ6 months → 6% This may be significantly reduced with perioperative intensive care Recent research has suggested that the perioperative risk of MI is not as high as previously thought The risk after a previous infarction is related 5 Core topics in perioperative medicine 1 less to the age of the infarction than to the functional status of the ventricles and the amount of myocardium... within 6 weeks of infarction as a time of high risk for a perioperative cardiac event (6 weeks ϭ mean healing time of the infarct related lesion) The period from 6 weeks to 3 months is of intermediate risk In uncomplicated cases, there appears to be no benefit in delaying surgery more than 3 months after a MI This is in contrast to the research of the 1980s The important questions to ask when seeing... Anaesthesia 1988; 43(7): 543–551 18 3 Perioperative care of children Warren Fisher Introduction 20 Preoperative preparation 20 Assessment 20 Common problems 21 Postoperative care of children 23 19 Core topics in perioperative medicine Introduction Children present a range of problems for their carers They present in a range of ages, a range of sizes and with a range of clinical conditions greatly different... Prostate surgery 4 *Combined incidence of cardiac death and non-fatal myocardial infarction † Further preoperative cardiac testing is not generally required Perioperative management of cardiovascular disease Table 1.3 Goldman cardiac risk index Finding Score Evidence of uncontrolled cardiac failure, e.g third heart sound, elevated jugulovenous pressure 11 Myocardial infarction within 6 months 10 Ventricular... should stop smoking Nicotine is an adrenergic agonist which increases blood pressure, increases myocardial oxygen demand and may reduce coronary blood flow Carbon monoxide in cigarette smoke combines avidly with haemoglobin to form carboxyhaemoglobin, which cannot carry oxygen These effects are reduced after 12–24 h abstinence Cigarette smoke also reduces ciliary and immunological function in the lungs .
CORE TOPICS IN PERIOPERATIVE MEDICINE
CORE TOPICS IN PERIOPERATIVE
MEDICINE
by
Jonathan Hudsmith BM FRCA
Department. Michael Lindop
10 .Perioperative management of endocrine disease 79
Dan Wheeler and Ingrid Wilkins
11 .Perioperative management of diabetes 91
Mike Masding and
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